Cardiac Masses on Cardiac CT: A Review

Abstract

Cardiac masses are rare entities that can be broadly categorized as either neoplastic or non-neoplastic. Neoplastic masses include benign and malignant tumors. In the heart, metastatic tumors are more common than primary malignant tumors. Whether incidentally found or diagnosed as a result of patients' symptoms, cardiac masses can be identified and further characterized by a range of cardiovascular imaging options. While echocardiography remains the first-line imaging modality, cardiac computed tomography (cardiac CT) has become an increasingly utilized modality for the assessment of cardiac masses, especially when other imaging modalities are non-diagnostic or contraindicated. With high isotropic spatial and temporal resolution, fast acquisition times, and multiplanar image reconstruction capabilities, cardiac CT offers an alternative to cardiovascular magnetic resonance imaging in many patients. Additionally, cardiac masses may be incidentally discovered during cardiac CT for other reasons, requiring imagers to understand the unique features of a diverse range of cardiac masses. Herein, we define the characteristic imaging features of commonly encountered and selected cardiac masses and define the role of cardiac CT among noninvasive imaging options.

Keywords: Cardiac computed tomography; Cardiac mass; Coronary computed tomographic angiography; Lipoma; Metastasis; Myxoma; Neoplasm; Pericardial cyst; Sarcoma; Teratoma; Thrombus; Tumor.

Fig. 1

Atrial myxoma. (a) Apical four-chamber view on transthoracic echocardiogram demonstrating a large mass occupying the majority of the left atrial cavity. (b) Non-contrast axial image faintly demonstrating the large left atrial mass. (c-e) Cardiac CT angiography images demonstrating a large, low attenuating mass with a small stalk attached to the fossa ovale, consistent with a large left atrial myxoma. Note the patchy, non-homogenous contrast enhancement

Fig. 2

Lipoma. Non-gated MDCT images in the axial and sagittal oblique planes from a 65-year-old female incidentally demonstrate a fatty mass in the posterior and superior region of the interatrial septum consistent with an interatrial lipoma (arrow). Right atrium (RA), Right ventricular outflow tract (RVOT), Left atrium (LA), Left ventricle (LV), Aorta (Ao) Superior vena cava (SVC), Right pulmonary artery (RPA). *Reproduced with permission from [17]

Fig. 3

Papillary fibroelastoma. CCT demonstrates a hypodense, microlobulated mass attached via a short stalk to the aortic valve on the aortic surface of the right coronary cusp (a-c). A transesophageal echocardiogram (TEE), mid-esophageal short-axis view of the aortic root, demonstrates a mobile echodense mass attached to the right coronary cusp (d). Gross examination following resection revealed a 1.1 × 1.3 × 1.2 cm tan-pink, friable, soft mass with a short stalk and a micronodular appearance, a typical feature for fibroelastoma (e). Histopathology of the mass demonstrates an avascular core surrounded by a loose matrix with multiple adjacent fronds covered by endothelium (f)

Fig. 4

Teratoma. a. Posteroanterior chest radiograph demonstrating a mass in the aortopulmonary window (arrow). b. Contrast non-gated axial CT image demonstrating a cystic pericardial mass. Subsequent cardiac MR suggested possible solid components atypical for a simple pericardial cysts. Pathological analysis post-resection identified the mass as a teratoma

Fig. 5

Angiosarcoma. a. Transesophageal echocardiogram demonstrating a large, lobulated mass in the right atrium. b. Contrast non-gated cardiac CT demonstrating a hypodense, multilobular mass in the right atrium. The mass invaded into the pericardial space. Aorta (Ao), Left atrium (LA), Left ventricle (LV), Right atrium (RA)

Fig. 6

Rhabdomyosarcoma. a. Non-gated contrast CT demonstrating a large mass in the left atrium with heterogenous contrast enhancement (black arrows). b. Transthoracic echocardiogram demonstrates a large mass involving the mitral valve apparatus. Pathology was consistent with a rhabdomyosarcoma. *Reproduced with permission from [25]

Fig. 7

Lipomatous hypertrophy of the interatrial septum. Cardiac CT demonstrating a mass with fat-attenuation which spares the fossa ovalis (*) consistent with lipomatous hypertrophy of the interatrial septum. Note that the mass also extends to involve the posterior wall of the right atrium and crista terminalis (arrow), which may be seen in cases of more extensive lipomatous hypertrophy

Fig. 8

Left ventricular thrombus. Curved multiplanar image demonstrating a severe stenosis in the ostial portion of the left anterior descending artery (arrow) due to non-calcified plaque. b. Axial image from the same patient demonstrating a large hypodensity in the left ventricular apex consistent with thrombus

Fig. 9

Left ventricular pseudoaneurysm. Contrast cardiac CT demonstrating a large pseudoaneurysm (Ps) of the left ventricular (LV) basal lateral wall as seen in oblique (a-c) and volume rendered (d) reformations. The patient had a history of a remote myocardial infarction that was complicated by cardiac tamponade due to left ventricular rupture. Note: thrombus (*) is visualized within the pseudoaneurysm and the rim of the pseudoaneurysm is calcified. LA, left atrium; Cx, circumflex coronary artery. *Reproduced with permission from [34]

Fig. 10

Pericardial cyst. (left) anterior chest X-ray suggestive of a mass at the right costophrenic angle. (right) contrast cardiac CT demonstrating that the mass correlates to a homogenous cyst in the right cardiophrenic angle most consistent with a benign pericardial cyst

Fig. 11

Valvular vegetation. Transesophageal echocardiogram (TEE), mid-esophageal short-axis (a) and long axis (b) views at peak diastole demonstrating a bicuspid aortic valve with fusion of the left and right coronary cusps and a 1.5 × 1.0 cm mobile echodensity attached to the right and non-coronary cusp. TEE long axis view with color Doppler demonstrates severe, eccentric aortic insufficiency (c). Cardiac CT 3D image reconstruction of a closed bicuspid aortic valve demonstrates the relationship of the mass (depicted in red) at the right and the non-coronary cusp with perforation of the non-coronary cusp (arrow) reproduced on 2D CCT short axis view (insert) with a regurgitant orifice area measuring 0.8 mm² consistent with severe aortic regurgitation (d). Orthogonal 2D CCT 3-chamber views demonstrate a hypodense, irregular mobile mass (e) with associated flail leaflet and valve perforation (arrow) (f)

Fig. 12

Crista terminalis. Serial axial images (a-d) of a coronary CT angiography study demonstrating the normal appearance of the crista terminalis (arrow) extending in the cranio-caudal region in the posterior wall of the right atrium